May 30, 2017

Prenatal Genetic Testing: What Midwives and Clients Need to Know

People seek genetic counseling or prenatal genetic testing for a variety of reasons, including a family history of a genetic condition or to learn more about factors that contribute to a higher chance for certain types of genetic conditions. While the personal beliefs and values of clients will ultimately determine their decisions regarding prenatal genetic testing, having timely access to accurate information regarding the purpose and types of testing available should also be part of their informed decision­ making. Midwives have an important role in providing basic Source: National Human Genome Research information about prenatal genetic Institute testing options and making referrals to genetics counselors when indicated. However, midwives' knowledge and utilization of genetics counselors and antenatal screening varies across the country, often influenced in part by whether midwives have integrated or streamlined access to the necessary services.

The NACPM webinar, Genetic Testing in the Community Context, features Melissa Cheyney, PhD, CPM, LDM, and Jazmine Gabriel, PhD, MS, who will cover the basics regarding the various screening tests, the false positive rates, chance of miscarriage with diagnostic testing, and the utility of genetic information for pregnancy planning and improving birth outcomes. They will also report on their recent study of utilization of genetic counseling and antenatal testing among midwives in Vermont with a focus on the clinical and socio­political implications of this work. The webinar is offered live this Thursday, June 1, 2017 from 2:00 to 3:30 pm Eastern time and will be available as a recording the following week.

Additional resources that midwives will find helpful include:

Client decision aids developed by the American Congress of Obstetricians and Gynecologists, including Frequently Asked Questions with an extensive glossary of terms, and a Prenatal Genetic Testing Chart Infographic.

An overview of genetic counseling services provided by the Center for Disease Control and Prevention. Genetic counselors are specially­trained professionals who help people learn about genetic conditions, find out their chances of being affected by or having a child or other family member with a genetic condition, and make informed decisions about testing and treatment.

Information about the Genetic Testing Registry (GTR®), a central location for voluntary submission of genetic test information by providers. The scope of the registry includes the test's purpose, methodology, validity, evidence of the test's usefulness, and laboratory contacts and credentials. This site also includes links to tutorials and directories of genetic counselors searchable by location.

Midwives ­ Are Your Charting Practices Up­to­Date?

Did you know that S.O.A.P charting is no longer the preferred method for documenting your care? The Center for Medicare and Medicaid has issued guidelines that support Clinical Documentation Improvement (CDI) initiatives. Within these guidelines, every encounter should be organized with these three elements: History, Exam, and Medical Decision­Making.

Nancy Koerber, CPM, CPC, recently provided an excellent introduction to the changes occurring in the health care system that will impact midwives and the way that midwives should now be keeping records in the NACPM webinar Charting for Midwives ­ Getting Credit For What You Do. A recording of the webinar, including the very informative discussion that followed her presentation, is now available Nancy Koerber, here.This webinar is eligible for NARM Bridge Certificate CPM, CPC Category 3 CEUs. Nancy is a midwife who learned about billing on her own, like many others with small home birth practices, but eventually decided to pursue training and is now a Certified Professional Coder with extensive experience in a variety of medical practices and settings. She notes that:

The U.S. health care system is moving past fee­for­service billing. In the future, the providers will be reimbursed based upon quality care and the results demonstrated in their patients. Every provider will be profiled to determine whether they meet benchmarks that demonstrate the value they add to their patients' care. The documentation provided will integrate widely in the healthcare system with other providers, hospitals, labs, and pharmacies.

While midwifery care has been shown to produce good outcomes with fewer expensive interventions and community­based care fits well with projections for more healthcare services moving into outpatient settings, midwives who haven't transitioned to the new charting methods are likely to experience problems sharing records with other providers and getting paid by insurers.

Nancy made numerous recommendations based on her training and experience. She outlined what should be included in the History, Exam and Medical Decision­Making elements of the record. For example, everything pertinent to the current visit should be included in the record, including information gathered in previous visits or consults. Nancy says, "The note must stand alone. Everything that a third­party reader may need to know about this patient encounter must be documented in the current record associated with that day's visit." Labs and preventive care services must be justified. Counseling and education must be documented and the length of time spent appropriately charted. She cautioned against using abbreviations or acronyms and other short­hand terminology that may not be understood by others reading the chart.

Participants had lots of questions about electronic medical records, asked for chart examples, and expressed interest in more information about coding and billing. Stay tuned! Nancy has offered to conduct a follow­up webinar which we will schedule this summer.

Remembering Dorothea Lang ­ A Midwife By Jo Anne Myers­Ciecko

Dorothea Lang, CNM, MPH, FACNM, was an innovator, a strategist, a mentor, and a leader. She passed away on May 16, 2017 at the age of 84. I first met Dorothea in the early 1980s when, advocating for direct­entry midwifery, she reached out to home birth midwives and advocates like myself. We did not agree on everything. She was much more interested in promoting hospital­based midwifery than I was. She did not understand the desire of many in our movement to retain community­based apprenticeship and to resist the drive for advanced degrees in midwifery. Nevertheless, we shared a common commitment to midwifery as a profession, independent of nursing and medicine, and a vision for midwifery as the standard of care with an emphasis on the value of normal physiologic birth.

Dorothea Lang (right) provided invaluable encouragement to midwives like Marge Mansfield (center) and advocates like Jo Anne Myers­Ciecko (left) as we worked on behalf of direct­ entry midwifery in the 1980s

Dorothea completed her nurse­midwifery training in 1959 and forged a path for nurse­midwifery in New York City, overcoming numerous obstacles to develop maternal and infant care programs providing midwifery care to underserved populations in an era when fewer than 50 nurse­midwives were actually practicing full­scope midwifery in the entire United States. Along the way, she made sure that hundreds of students and new graduates had the opportunity to gain much­needed experience and encouraged many to move on to other cities and states where she knew midwives were needed.

Dorothea held numerous leadership positions, serving as President of the American College of Nurse­Midwives from 1975 to 1977 and as the Regional Representative for the Americas to the International Confederation of Midwives in the 1980s. In recent years, she also represented the ICM at the United Nations! She was a regular attendee at MANA conferences and other midwifery gatherings, looking to strengthen fragile bridges and often providing helpful guidance as we sought our own way forward for the recognition of direct­entry midwifery. She encouraged NACPM to step up to membership in the ICM. She has been a generous donor to numerous midwifery organizations and educational programs, including NACPM, and we will be forever grateful.

See other tributes to Dorothea from the ACNM here and from the ICM here.

Upcoming Webinar:

Genetic Testing In The Community Context Thursday, June 1, 2017 from 2:00 to 3:30 pm Eastern time.

Designed for midwives providing care in the community context where access to genetics counselors and antenatal screening may be less streamlined and integrated. Melissa Cheney, BA, BS, MA, PhD, CPM, LDM and Jazmin Gabriel, MS, PhD, MA, BA will review current prenatal genetic testing options, indications for referring to genetic counseling, and approaches for accessing information about cost and insurance Melissa Cheney coverage of testing and counseling. They will also BA, BS, MA, PhD, describe the strengths and limitations of screening CPM, LDM tests, carrier screening, and diagnostic testing. What are the frequently asked questions about the false positive rates of screening tests, the chance of miscarriage with diagnostic testing, and the clinical utility of genetic information for pregnancy planning and improving birth outcomes? Also, you will receive an overview of the findings from a recent study on the utilization of genetic counseling and antenatal testing among midwives in Vermont with a focus on the clinical and socio­political Jazmin Gabriel MS, PhD, MA, BA implications of this work.

Register here for this free webinar

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